Cytoreductive surgery and HIPEC offer hope to patients with difficult to treat abdominal cancers

May 10, 2023
a doctor and patient pose in an exam room with a small framed artwork
Retired art teacher Margaret Carroll presented Dr. Jeffrey Sutton with a painting of a Lowcountry marsh after he treated her for a cancer in her appendix. Photo provided

Patients with tumors within the abdominal cavity often experience few or no symptoms. In addition, when the tumor spreads from its original location to the lining of the abdominal cavity, also known as the peritoneum, it can be difficult to treat using conventional therapies. That’s because this barrier is designed to do one of two things: facilitate containment within the abdominal cavity or keep things out. And the peritoneum is no exception. It lines the abdominal organs while allowing blood vessels, lymphatic vessels and nerves to pass through. It is also extraordinarily effective at keeping everything else out, which makes treating cancer in the abdominal cavity difficult with traditional systemic chemotherapy.

Often, these difficult-to-treat cancers are diagnosed during studies to work up other medical conditions. That was the case for Margaret Carroll, a retired art teacher from Murrells Inlet.

In the summer of 2021, she went to the emergency room at her local hospital for what seemed to be an abdominal hernia. Testing showed she not only had a hernia, but she also had a mass on her appendix.

a woman and doctor talk in an exam room 
Margaret Carroll talks with Dr. Jeffrey Sutton. She was pleased that he had studied her case before he even arrived at MUSC. Photo by Clif Rhodes

She was referred to MUSC Hollings Cancer Center, the only NCI-designated cancer center in South Carolina, where she was diagnosed with a low-grade appendiceal mucinous neoplasm, or LAMN. This rare tumor begins in the lining of the appendix where the cells produce a sticky jelly-like mucin that can spread throughout the abdominal cavity, coating various organs and potentially causing bowel blockages.

Carroll learned that her treatment would include additional surgery and HIPEC, a unique type of chemotherapy delivery. HIPEC, which stands for hyperthermic intraperitoneal chemotherapy, is a highly concentrated heated chemotherapy treatment delivered directly to the abdominal cavity during surgery. HIPEC is often used to treat select patients with cancers of the abdominal or peritoneal cavity.

HIPEC is typically a two-step procedure.

The first step involves surgical removal of all signs of cancer that surgeons can see on the organs. The second step utilizes a heated chemotherapy to kill any remaining microscopic cancer cells that can’t be seen or felt. HIPEC allows for exposure of the cancer cells to a more intense dose of chemotherapy delivered directly to the abdomen, which can destroy more cancer cells than traditional IV chemotherapy. At the same time, it decreases the toxic side effects of chemotherapy, since greater than 90% of the chemotherapy drugs stay in the abdomen.

“In treating patients with cytoreductive surgery and HIPEC, our goal is to surgically remove all of the macroscopic disease we can see,” said Jeffrey Sutton, M.D., who joined MUSC Health in 2021 to lead the multidisciplinary team at Hollings that performs HIPEC for peritoneal surface malignancies. “After this is completed, we temporarily close the abdomen to infuse the heated chemotherapy to kill all the tiny microscopic cells that may persist.”

"Since we each view and treat cancer through different lenses, it's helpful to have those different viewpoints to determine which patients may benefit most from this type of novel treatment."

Jeffrey Sutton, M.D.

"We always present these complex cases at our multidisciplinary tumor board, which comprises surgical oncologists, medical and radiation oncologists, radiologists, gastroenterologists and pathologists,” explained Sutton. “Since we each view and treat cancer through different lenses, it's helpful to have those different viewpoints to determine which patients may benefit most from this type of novel treatment.”

“Dr. Sutton is exceedingly well trained, having completed his surgical oncology fellowship at the University of Pittsburgh Medical Center, one of the highest-volume HIPEC surgery centers in the U.S.,” said David Mahvi, M.D., chief of surgical oncology. “We are fortunate to have him lead the effort to expand the HIPEC program at MUSC Health so patients like Mrs. Carroll can receive this highly specialized treatment close to their home.”

It so happened that Sutton’s arrival at MUSC Health timed perfectly with Carroll’s treatment plan; in fact, hers was the first cytoreductive surgery and HIPEC he performed at MUSC. “Having discussed her case with several members of the tumor board before I even arrived at MUSC, I was so familiar with her clinical history that we were able to meet Margaret and schedule her for surgery soon after my arrival. She did great,” he said, adding that her prognosis is excellent.

Sutton explained that HIPEC is a highly specialized procedure, requiring an expert surgical team and state-of-the-art equipment, “MUSC Health is one of the few centers in South Carolina to perform cytoreductive surgery and HIPEC,” he said.

Carroll said she always felt she was in good hands and appreciated the exceptional care she received from her medical team at Hollings Cancer Center. She said she was well-prepared for the surgery – even before meeting Sutton. “I am so appreciative of the whole cancer team who worked so closely together to coordinate my care and kept me informed throughout the process,” she said. “Everything was so organized leading up to my surgery.”

“Dr. Sutton is not only exceptionally well-trained, offering patients with these difficult-to-treat cancers this cutting-edge treatment option, he’s also quite delightful – and that made things so much easier for me during this difficult time,” she added.

Now fully recovered, she has returned to her first love – painting. At a recent follow-up visit, she presented Sutton with a painting of a Lowcountry marsh. Sutton said the painting means a lot to him.

“Margaret was one of my first patients at MUSC Health, someone I’ll always remember,” he said. “Her painting hangs on the wall in my office.”

At Hollings, patients with the following cancers can be considered for cytoreductive surgery and HIPEC:

Peritoneal carcinomatosis resulting from cancers of the:

  • Appendix
  • Colon and rectum
  • Stomach
  • Small bowel

As well as:

  • Pseudomyxoma peritonei, resulting from a ruptured appendiceal mucocele (low-grade appendiceal mucinous neoplasm, or LAMN)
  • Primary peritoneal mesothelioma